House Kids Registration - The House Modesto

Your name *

Email address *

Phone number *

Address *

House Kids Provides Services For Children Nursery Age to 6th Grade

Please choose one of the following:

House en Espanol first time family

Please do not enter a grade for Nursery age children, their DOB will be used

Relationship to Child *

Father

Mother

Step Parent

Other

Do Any of Your Children Have Special Needs? *

Yes

ARE THERE ANY CUSTODY ISSUES WITH YOUR CHILD/CHILDREN? *

Yes

Guardian Consent

If during any part of the children's service/program, medical attention is required by my child, House Kids at The House Modesto will provide appropriate first-aide treatment, contact the guardian and stay with the child until the guardian collects them. Medical care above and beyond this plan is my responsibility as the guardian. I authorize the leader in charge to take such action as may be necessary, including the calling of an ambulance and treatment by paramedics.

I understand photos and video will be taken and give permission for promotional footage to be used. No personal identifiers will be published outside of their photo/image.

Privacy Statement: We only collect information where it is necessary to provide a service to you, or when required by law. Access to personal information is restricted to staff and support staff who require information to provide a service to you. Personal information will not be shared with any organization or third party.

Electronic Signature

By selecting the "I ACCEPT" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I ACCEPT" you consent to be legally bound by this Agreement's terms and conditions.